Conjunctivitis is the most common reason for red eyes, accounting for about 35% of all eye problems seen in general practice. It occurs when the conjunctiva, the thin layer covering the white part of the eye, becomes inflamed. Conjunctivitis can be caused by an infection or an allergic reaction.

Infective conjunctivitis is inflammation of the conjunctiva caused by a viral, bacterial, or parasitic infection. The most common type of infective conjunctivitis is viral, with adenoviruses being the main culprits. Bacterial conjunctivitis is also common and is usually caused by Streptococcus pneumoniae, Staphylococcus aureus, or Haemophilus influenzae.

The symptoms of infective conjunctivitis include sudden redness of the conjunctiva, discomfort described as a gritty or burning sensation, watering of the eyes, and discharge that may temporarily blurry vision. It can be challenging to differentiate between viral and bacterial conjunctivitis based on symptoms alone.

Here are some key features that can help distinguish between viral and bacterial conjunctivitis:

Features suggestive of viral conjunctivitis:
– Mild to moderate redness of the conjunctiva
– Presence of follicles on the inner surface of the eyelids
– Swelling of the eyelids
– Small, pinpoint bleeding under the conjunctiva
– Pseudomembranes (thin layers of tissue) may form on the inner surface of the eyelids in severe cases, often caused by adenovirus
– Less discharge (usually watery) compared to bacterial conjunctivitis
– Mild to moderate itching
– Symptoms of upper respiratory tract infection and swollen lymph nodes in front of the ears

Features suggestive of bacterial conjunctivitis:
– Purulent or mucopurulent discharge with crusting of the eyelids, which may cause them to stick together upon waking
– Mild or no itching
– Swollen lymph nodes in front of the ears, which are often present in severe bacterial conjunctivitis
– If the discharge is copious and mucopurulent, infection with Neisseria gonorrhoeae should be considered.

By considering these distinguishing features, healthcare professionals can better diagnose and manage cases of conjunctivitis.

Amiodarone functions by inhibiting voltage-gated potassium channels, leading to an extended repolarization period and decreased excitability of the heart muscle.

Further Reading:

In the management of respiratory and cardiac arrest, several drugs are commonly used to help restore normal function and improve outcomes. Adrenaline is a non-selective agonist of adrenergic receptors and is administered intravenously at a dose of 1 mg every 3-5 minutes. It works by causing vasoconstriction, increasing systemic vascular resistance (SVR), and improving cardiac output by increasing the force of heart contraction. Adrenaline also has bronchodilatory effects.

Amiodarone is another drug used in cardiac arrest situations. It blocks voltage-gated potassium channels, which prolongs repolarization and reduces myocardial excitability. The initial dose of amiodarone is 300 mg intravenously after 3 shocks, followed by a dose of 150 mg after 5 shocks.

Lidocaine is an alternative to amiodarone in cardiac arrest situations. It works by blocking sodium channels and decreasing heart rate. The recommended dose is 1 mg/kg by slow intravenous injection, with a repeat half of the initial dose after 5 minutes. The maximum total dose of lidocaine is 3 mg/kg.

Magnesium sulfate is used to reverse myocardial hyperexcitability associated with hypomagnesemia. It is administered intravenously at a dose of 2 g over 10-15 minutes. An additional dose may be given if necessary, but the maximum total dose should not exceed 3 g.

Atropine is an antagonist of muscarinic acetylcholine receptors and is used to counteract the slowing of heart rate caused by the parasympathetic nervous system. It is administered intravenously at a dose of 500 mcg every 3-5 minutes, with a maximum dose of 3 mg.

Naloxone is a competitive antagonist for opioid receptors and is used in cases of respiratory arrest caused by opioid overdose. It has a short duration of action, so careful monitoring is necessary. The initial dose of naloxone is 400 micrograms, followed by 800 mcg after 1 minute. The dose can be gradually escalated up to 2 mg per dose if there is no response to the preceding dose.

It is important for healthcare professionals to have knowledge of the pharmacology and dosing schedules of these drugs in order to effectively manage respiratory and cardiac arrest situations.

This question discusses the prioritization of patient care, specifically focusing on the initial management of acutely unwell patients. The sequence followed in such cases is known as ‘ABCDE’, which stands for airway, breathing, circulation, disability, and exposure. It is crucial to call for help as soon as possible, as the patient’s condition may deteriorate rapidly. If a patient’s consciousness level is dropping, urgent assistance is required, and it is unlikely that you will be able to handle the situation independently.

While waiting for the resuscitation team to arrive, you will be occupied with managing the patient. Therefore, it is not appropriate to make a phone call to the Emergency Department consultant for advice. Although the Emergency Department nurses may be helpful, it is essential to call the resuscitation team first. Continuing to handle the situation alone, regardless of the patient’s clinical condition, indicates a failure to recognize the need for assistance in this scenario.

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 certain cases, especially in immunocompromised individuals and intravenous drug users. Gram-negative organisms like Escherichia coli and Mycobacterium tuberculosis can also cause discitis, particularly in cases of Pott’s disease.

There are several risk factors that increase the likelihood of developing discitis. These include having undergone spinal surgery (which occurs in about 1-2% of patients 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, a refusal to walk may also be a symptom.

When diagnosing discitis, magnetic resonance imaging (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. Computed tomography (CT) scanning is also not very sensitive in detecting discitis.

Treatment for discitis involves hospital admission for intravenous antibiotics. Before starting the antibiotics, it is recommended to send three sets of blood cultures and a full set of blood tests, including a C-reactive protein (CRP) test, to the laboratory.

A typical antibiotic regimen for discitis would include intravenous flucloxacillin 2 g every 6 hours as the first-line treatment if there is no penicillin allergy. Intravenous vancomycin may be used if the infection was acquired in the hospital, if there is a high risk of methicillin-resistant Staphylococcus aureus (MRSA) infection, or if there is a documented penicillin allergy.

The Apgar score is a straightforward way to evaluate the well-being of a newborn baby right after birth. It consists of five criteria, each assigned a score ranging from zero to two. Typically, the assessment is conducted at one and five minutes after delivery, with the possibility of repeating it later if the score remains low. A score of 7 or higher is considered normal, while a score of 4-6 is considered fairly low, and a score of 3 or below is regarded as critically low. To remember the five criteria, you can use the acronym APGAR:

Appearance
Pulse rate
Grimace
Activity
Respiratory effort

The Apgar score criteria are as follows:

Score of 0:
Appearance (skin color): Blue or pale all over
Pulse rate: Absent
Reflex irritability (grimace): No response to stimulation
Activity: None
Respiratory effort: Absent

Score of 1:
Appearance (skin color): Blue at extremities (acrocyanosis)
Pulse rate: Less than 100 per minute
Reflex irritability (grimace): Grimace on suction or aggressive stimulation
Activity: Some flexion
Respiratory effort: Weak, irregular, gasping

Score of 2:
Appearance (skin color): No cyanosis, body and extremities pink
Pulse rate: More than 100 per minute
Reflex irritability (grimace): Cry on stimulation
Activity: Flexed arms and legs that resist extension
Respiratory effort: Strong, robust cry

Nitrous oxide should not be used in cases where there is trapped air, such as pneumothorax. This is because nitrous oxide can diffuse into the trapped air and increase the pressure, which can be harmful. This can be particularly dangerous in conditions like pneumothorax, where the trapped air can expand and affect breathing, or in cases of intracranial air after a head injury, trapped air after a recent underwater dive, or recent injection of gas into the eye.

Further Reading:

Entonox® is a mixture of 50% nitrous oxide and 50% oxygen that can be used for self-administration to reduce anxiety. It can also be used alongside other anesthesia agents. However, its mechanism of action for anxiety reduction is not fully understood. The Entonox bottles are typically identified by blue and white color-coded collars, but a new standard will replace these with dark blue shoulders in the future. It is important to note that Entonox alone cannot be used as the sole maintenance agent in anesthesia.

One of the effects of nitrous oxide is the second-gas effect, where it speeds up the absorption of other inhaled anesthesia agents. Nitrous oxide enters the alveoli and diffuses into the blood, displacing nitrogen. This displacement causes the remaining alveolar gases to become more concentrated, increasing the fractional content of inhaled anesthesia gases and accelerating the uptake of volatile agents into the blood.

However, when nitrous oxide administration is stopped, it can cause diffusion hypoxia. Nitrous oxide exits the blood and diffuses back into the alveoli, while nitrogen diffuses in the opposite direction. Nitrous oxide enters the alveoli much faster than nitrogen leaves, resulting in the dilution of oxygen within the alveoli. This can lead to diffusion hypoxia, where the oxygen concentration in the alveoli is diluted, potentially causing oxygen deprivation in patients breathing air.

There are certain contraindications for using nitrous oxide, as it can expand in air-filled spaces. It should be avoided in conditions such as head injuries with intracranial air, pneumothorax, recent intraocular gas injection, and entrapped air following a recent underwater dive.

When evaluating a disturbed or violent patient, your own safety should be the top priority. It is essential that the room you use for the examination has certain features to ensure your well-being. Firstly, there should be an internal inspection window that allows the staff to regularly check on both you and the patient. Additionally, the room should have an unimpeded exit, preferably with an outward opening door that is easy to exit through. It is also crucial to choose a room that is close to well-staffed areas, as this can provide immediate assistance if needed.

It is highly recommended to avoid examining patients in isolated areas, as it significantly increases the risk of harm to the assessor. While the room should be comfortable, it is unnecessary to have excessive furnishings. In fact, having too much furniture and unnecessary equipment can pose a threat, as they can be used as weapons by the patient. Therefore, it is ideal to remove any excess furniture and unnecessary equipment from the room. In this case, an examination couch is not required and should be avoided, as it could potentially be used as a weapon.

A secure locking mechanism is not necessary for the room, and it should be easily accessible to other staff members during the assessment. It is important to note that the room should not be used as a detainment area for the patient, and they should never be locked inside. By following these guidelines and ensuring the room has the recommended features, you can prioritize your safety while examining disturbed or violent patients.

ATLS guidelines now suggest administering only 1 liter of crystalloid fluid during the initial assessment. If patients do not respond to the crystalloid, it is recommended to quickly transition to blood products. Studies have shown that infusing more than 1.5 liters of crystalloid fluid is associated with higher mortality rates in trauma cases. Therefore, it is advised to prioritize the early use of blood products and avoid large volumes of crystalloid fluid in trauma patients. In cases where it is necessary, massive transfusion should be considered, defined as the transfusion of more than 10 units of blood in 24 hours or more than 4 units of blood in one hour. For patients with evidence of Class III and IV hemorrhage, early resuscitation with blood and blood products in low ratios is recommended.

Based on the findings of significant trials, such as the CRASH-2 study, the use of tranexamic acid is now recommended within 3 hours. This involves administering a loading dose of 1 gram intravenously over 10 minutes, followed by an infusion of 1 gram over eight hours. In some regions, tranexamic acid is also being utilized in the prehospital setting.

Bacterial vaginosis (BV) is a common condition that affects up to a third of women during their childbearing years. It occurs when there is an overgrowth of bacteria, specifically Gardnerella vaginalis. This bacterium is anaerobic, meaning it thrives in environments without oxygen. As it multiplies, it disrupts the balance of bacteria in the vagina, leading to a rise in pH levels and a decrease in lactic acid-producing lactobacilli. It’s important to note that BV is not a sexually transmitted infection.

The main symptom of BV is a greyish discharge with a distinct fishy odor. However, it’s worth mentioning that around 50% of affected women may not experience any symptoms at all.

To diagnose BV, healthcare providers often use Amsel’s criteria. This involves looking for the presence of three out of four specific criteria: a vaginal pH greater than 4.5, a positive fishy smell test when potassium hydroxide is added, the presence of clue cells on microscopy, and a thin, white, homogeneous discharge.

The primary treatment for BV is oral metronidazole, typically taken for 5-7 days. This medication has an initial cure rate of about 75%. It’s crucial to provide special care to pregnant patients diagnosed with BV, as it has been linked to an increased risk of late miscarriage, early labor, and chorioamnionitis. Therefore, prompt treatment for these patients is of utmost importance.

In this case, the patient opens his eyes to voice, which corresponds to a score of 3 on the eye opening component. The patient localizes to pain, indicating a purposeful motor response, which corresponds to a score of 5 on the motor response component. However, the patient’s speech is slurred and he appears disoriented, suggesting an impaired verbal response. This would correspond to a score of 4 on the verbal response component.

To calculate the GCS, we sum up the scores from each component. In this case, the patient’s GCS would be 3 + 4 + 5 = 12

Further Reading:

Indications for CT Scanning in Head Injuries (Adults):
– CT head scan should be performed within 1 hour if any of the following features are present:
– GCS < 13 on initial assessment in the ED
– GCS < 15 at 2 hours after the injury on assessment in the ED
– Suspected open or depressed skull fracture
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– Post-traumatic seizure
– New focal neurological deficit
– > 1 episode of vomiting

Indications for CT Scanning in Head Injuries (Children):
– CT head scan should be performed within 1 hour if any of the features in List 1 are present:
– Suspicion of non-accidental injury
– Post-traumatic seizure but no history of epilepsy
– GCS < 14 on initial assessment in the ED for children more than 1 year of age
– Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
– At 2 hours after the injury, GCS < 15
– Suspected open or depressed skull fracture or tense fontanelle
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– New focal neurological deficit
– For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

– CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
– Loss of consciousness lasting more than 5 minutes (witnessed)
– Abnormal drowsiness
– Three or more discrete episodes of vomiting
– Dangerous mechanism of injury (high-speed road traffic accident, fall from a height.

Second degree frostbite is characterized by tissue necrosis that affects both the epidermis and a variable depth of the dermis. However, there is still some healthy dermis present, which allows for regeneration and recovery of the skin. This type of frostbite is often referred to as partial thickness. Clinically, it is observed as the formation of blisters filled with clear or milky fluid on the surface of the skin, accompanied by redness and swelling.

Further Reading:

Hypothermia is defined as a core temperature below 35ºC and can be graded as mild, moderate, severe, or profound based on the core temperature. When the core temperature drops, the basal metabolic rate decreases and cell signaling between neurons decreases, leading to reduced tissue perfusion. This can result in decreased myocardial contractility, vasoconstriction, ventilation-perfusion mismatch, and increased blood viscosity. Symptoms of hypothermia progress as the core temperature drops, starting with compensatory increases in heart rate and shivering, and eventually leading to bradyarrhythmias, prolonged PR, QRS, and QT intervals, and cardiac arrest.

In the management of hypothermic cardiac arrest, ALS should be initiated with some modifications. The pulse check during CPR should be prolonged to 1 minute due to difficulty in obtaining a pulse. Rewarming the patient is important, and mechanical ventilation may be necessary due to stiffness of the chest wall. Drug metabolism is slowed in hypothermic patients, so dosing of drugs should be adjusted or withheld. Electrolyte disturbances are common in hypothermic patients and should be corrected.

Frostbite refers to a freezing injury to human tissue and occurs when tissue temperature drops below 0ºC. It can be classified as superficial or deep, with superficial frostbite affecting the skin and subcutaneous tissues, and deep frostbite affecting bones, joints, and tendons. Frostbite can be classified from 1st to 4th degree based on the severity of the injury. Risk factors for frostbite include environmental factors such as cold weather exposure and medical factors such as peripheral vascular disease and diabetes.

Signs and symptoms of frostbite include skin changes, cold sensation or firmness to the affected area, stinging, burning, or numbness, clumsiness of the affected extremity, and excessive sweating, hyperemia, and tissue gangrene. Frostbite is diagnosed clinically and imaging may be used in some cases to assess perfusion or visualize occluded vessels. Management involves moving the patient to a warm environment, removing wet clothing, and rapidly rewarming the affected tissue. Analgesia should be given as reperfusion is painful, and blisters should be de-roofed and aloe vera applied. Compartment syndrome is a risk and should be monitored for. Severe cases may require surgical debridement of amputation.

Pelvic inflammatory disease (PID) is a pelvic infection that affects the upper female reproductive tract, including the uterus, fallopian tubes, and ovaries. It is typically caused by an ascending infection from the cervix and is commonly associated with sexually transmitted diseases like chlamydia and gonorrhea. In the UK, genital Chlamydia trachomatis infection is the most common cause of PID seen in genitourinary medicine clinics.

PID can often be asymptomatic, but when symptoms are present, they may include lower abdominal pain and tenderness, fever, painful urination, painful intercourse, purulent vaginal discharge, abnormal vaginal bleeding, and tenderness in the cervix and adnexa. It is important to note that symptoms of ectopic pregnancy can be similar to those of PID, so a pregnancy test should be conducted for all patients with suspicious symptoms.

To investigate a possible case of PID, endocervical swabs should be taken to test for C. trachomatis and N. gonorrhoeae using nucleic acid amplification tests if available. Mild to moderate cases of PID can usually be managed in primary care or outpatient settings, while patients with severe disease should be admitted to the hospital for intravenous antibiotics. Signs of severe disease include a fever above 38°C, signs of a tubo-ovarian abscess, signs of pelvic peritonitis, or concurrent pregnancy.

Empirical antibiotic treatment should be initiated as soon as a presumptive diagnosis of PID is made clinically, without waiting for swab results. The current recommended outpatient treatment for PID is a single intramuscular dose of ceftriaxone 500 mg, followed by oral doxycycline 100 mg twice daily and oral metronidazole 400 mg twice daily for 14 days. An alternative regimen is oral ofloxacin 400 mg twice daily and oral metronidazole 400 mg twice daily for 14 days.

For severely ill patients in the inpatient setting, initial treatment includes intravenous doxycycline, a single-dose of intravenous ceftriaxone, and intravenous metronidazole. This is then followed by a switch to oral doxycycline and metronidazole to complete a 14-day treatment course. If a patient fails to respond to treatment, laparoscopy is necessary to confirm the diagnosis or consider alternative diagnoses.

Potassium-sparing diuretics, like spironolactone and amiloride, can raise the chances of developing hyperkalemia when taken alongside ACE inhibitors, such as ramipril, and angiotensin-II receptor antagonists, like losartan.

For more information, you can refer to the BNF section on ramipril interactions.

C. difficile infection is often linked to the use of certain antibiotics such as clindamycin, cephalosporins (particularly third and fourth generation), fluoroquinolones, and broad-spectrum penicillins. To treat C. difficile diarrhea, metronidazole and vancomycin are commonly prescribed.

Further Reading:

Clostridium difficile (C.diff) is a gram positive rod commonly found in hospitals. Some strains of C.diff produce exotoxins that can cause intestinal damage, leading to pseudomembranous colitis. This infection can range from mild diarrhea to severe illness. Antibiotic-associated diarrhea is often caused by C.diff, with 20-30% of cases being attributed to this bacteria. Antibiotics such as clindamycin, cephalosporins, fluoroquinolones, and broad-spectrum penicillins are frequently associated with C.diff infection.

Clinical features of C.diff infection include diarrhea, distinctive smell, abdominal pain, raised white blood cell count, and in severe cases, toxic megacolon. In some severe cases, diarrhea may be absent due to the infection causing paralytic ileus. Diagnosis is made by detecting Clostridium difficile toxin (CDT) in the stool. There are two types of exotoxins produced by C.diff, toxin A and toxin B, which cause mucosal damage and the formation of a pseudomembrane in the colon.

Risk factors for developing C.diff infection include age over 65, antibiotic treatment, previous C.diff infection, exposure to infected individuals, proton pump inhibitor or H2 receptor antagonist use, prolonged hospitalization or residence in a nursing home, and chronic disease or immunosuppression. Complications of C.diff infection can include toxic megacolon, colon perforation, sepsis, and even death, especially in frail elderly individuals.

Management of C.diff infection involves stopping the causative antibiotic if possible, optimizing hydration with IV fluids if necessary, and assessing the severity of the infection. Treatment options vary based on severity, ranging from no antibiotics for mild cases to vancomycin or fidaxomicin for moderate cases, and hospital protocol antibiotics (such as oral vancomycin with IV metronidazole) for severe or life-threatening cases. Severe cases may require admission under gastroenterology or GI surgeons.

Intubation is necessary for patients with a compromised airway. In comatose patients, a Glasgow Coma Scale (GCS) score of 8 or less indicates the need for intubation. According to NICE guidelines, immediate intubation and ventilation are advised in cases of coma where the patient is not responsive to commands, not speaking, and not opening their eyes. Other indications for intubation include the loss of protective laryngeal reflexes, ventilatory insufficiency as indicated by abnormal blood gases, spontaneous hyperventilation, irregular respirations, significantly deteriorating conscious level, unstable fractures of the facial skeleton, copious bleeding into the mouth, and seizures. In certain cases, intubation and ventilation should be performed before the patient begins their journey.

Further Reading:

Indications for CT Scanning in Head Injuries (Adults):
– CT head scan should be performed within 1 hour if any of the following features are present:
– GCS < 13 on initial assessment in the ED
– GCS < 15 at 2 hours after the injury on assessment in the ED
– Suspected open or depressed skull fracture
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– Post-traumatic seizure
– New focal neurological deficit
– > 1 episode of vomiting

Indications for CT Scanning in Head Injuries (Children):
– CT head scan should be performed within 1 hour if any of the features in List 1 are present:
– Suspicion of non-accidental injury
– Post-traumatic seizure but no history of epilepsy
– GCS < 14 on initial assessment in the ED for children more than 1 year of age
– Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
– At 2 hours after the injury, GCS < 15
– Suspected open or depressed skull fracture or tense fontanelle
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– New focal neurological deficit
– For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

– CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
– Loss of consciousness lasting more than 5 minutes (witnessed)
– Abnormal drowsiness
– Three or more discrete episodes of vomiting
– Dangerous mechanism of injury (high-speed road traffic accident, fall from a height)

During Bier’s block, the cuff is inflated to a pressure that is 100 mmHg higher than the patient’s systolic blood pressure. For example, if the systolic blood pressure is 150 mmHg, the cuff would be inflated to 250 mmHg. It is important to note that Bier’s block should not be performed if the systolic blood pressure is greater than 200 mmHg, as this is considered a contraindication. Therefore, the maximum pressure ever used during Bier’s block is 300mmHg.

Further Reading:

Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

This patient’s medical history suggests a diagnosis of acute coronary syndrome. It is important to provide pain relief as soon as possible. This can be achieved by administering GTN (sublingual or buccal), but if there is suspicion of an acute myocardial infarction (MI), intravenous opioids such as morphine should be offered.

Aspirin should be given to all patients with unstable angina or NSTEMI as soon as possible and should be continued indefinitely, unless there are contraindications such as a high risk of bleeding or aspirin hypersensitivity. A single loading dose of 300 mg should be given immediately after presentation.

For patients without a high risk of bleeding and no planned coronary angiography within 24 hours of admission, fondaparinux should be administered. However, if coronary angiography is planned within 24 hours, unfractionated heparin can be offered as an alternative to fondaparinux. For patients with significant renal impairment (creatinine above 265 micromoles per litre), unfractionated heparin should be considered, with dose adjustment based on clotting function monitoring.

Routine administration of oxygen is no longer recommended, but oxygen saturation should be monitored using pulse oximetry as soon as possible, preferably before hospital admission. Supplemental oxygen should only be given to individuals with an oxygen saturation (SpO2) below 94% who are not at risk of hypercapnic respiratory failure, aiming for an SpO2 of 94-98%. For individuals with chronic obstructive pulmonary disease at risk of hypercapnic respiratory failure, a target SpO2 of 88-92% should be achieved until blood gas analysis is available.

Bivalirudin, a specific and reversible direct thrombin inhibitor (DTI), is recommended by NICE as a potential treatment for adults with STEMI undergoing percutaneous coronary intervention.

For more information, refer to the NICE guidelines on the assessment and diagnosis of chest pain of recent onset.

Malaria is a contagious illness that is spread by female mosquitoes of the Anopheles genus. It is caused by a parasitic infection from the Plasmodium genus. There are five species of Plasmodium that can cause disease in humans: Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, and Plasmodium knowlesi.

The main symptom of malaria is the malarial paroxysm, which is a recurring cycle of cold, hot, and sweating stages. During the cold stage, the patient experiences intense chills, followed by an extremely hot stage, and finally a stage of profuse sweating. Upon examination, the patient may show signs of anemia, jaundice, and have an enlarged liver and spleen, but no signs of swollen lymph nodes.

Plasmodium falciparum is the most severe form of malaria and is responsible for the majority of deaths. Severe or complicated malaria is indicated by impaired consciousness, seizures, low blood sugar, anemia, kidney damage, difficulty breathing, and spontaneous bleeding. Given the presentation, it is likely that this case involves Plasmodium falciparum.

Currently, artemisinin-based combination therapy (ACT) is recommended for treating P. falciparum malaria. This involves combining fast-acting artemisinin-based compounds with a drug from a different class. Companion drugs include lumefantrine, mefloquine, amodiaquine, sulfadoxine/pyrimethamine, piperaquine, and chlorproguanil/dapsone. Artemisinin derivatives include dihydroartemisinin, artesunate, and artemether.

If ACT is not available, oral quinine or atovaquone with proguanil hydrochloride can be used. Quinine is highly effective but not well tolerated for long-term treatment, so it should be combined with another drug, usually oral doxycycline (or clindamycin for pregnant women and young children).

Severe or complicated falciparum malaria should be managed in a high dependency unit or intensive care setting. Intravenous artesunate is recommended for all patients with severe or complicated falciparum malaria, or those at high risk of developing severe disease (such as if more than 2% of red blood cells are infected), or

Patients with head injuries who show any signs of basal skull fracture, such as haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, or Battle’s sign, should undergo urgent CT imaging. Additionally, the following indications also warrant a CT scan: a Glasgow Coma Scale (GCS) score of less than 13 on initial assessment in the emergency department (ED), a GCS score of less than 15 at 2 hours after the injury on assessment in the ED, suspected open or depressed skull fracture, post-traumatic seizure, new focal neurological deficit, greater than 1 episode of vomiting, or the patient being on anticoagulation. If any of these signs are present, a CT scan should be performed within 1 hour, except for patients on anticoagulation who should have a CT scan within 8 hours if they do not have any other signs. However, if patients on anticoagulation do have any of the other signs, the CT scan should be performed within 1 hour.

Further Reading:

Indications for CT Scanning in Head Injuries (Adults):
– CT head scan should be performed within 1 hour if any of the following features are present:
– GCS < 13 on initial assessment in the ED
– GCS < 15 at 2 hours after the injury on assessment in the ED
– Suspected open or depressed skull fracture
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– Post-traumatic seizure
– New focal neurological deficit
– > 1 episode of vomiting

Indications for CT Scanning in Head Injuries (Children):
– CT head scan should be performed within 1 hour if any of the features in List 1 are present:
– Suspicion of non-accidental injury
– Post-traumatic seizure but no history of epilepsy
– GCS < 14 on initial assessment in the ED for children more than 1 year of age
– Paediatric GCS < 15 on initial assessment in the ED for children under 1 year of age
– At 2 hours after the injury, GCS < 15
– Suspected open or depressed skull fracture or tense fontanelle
– Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign)
– New focal neurological deficit
– For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

– CT head scan should be performed within 1 hour if none of the above features are present but two or more of the features in List 2 are present:
– Loss of consciousness lasting more than 5 minutes (witnessed)
– Abnormal drowsiness
– Three or more discrete episodes of vomiting
– Dangerous mechanism of injury (high-speed road traffic accident, fall from a height.

In cases of mixed acidosis, both the respiratory and metabolic systems play a role in causing the low pH levels. This means that the patient’s acidotic state is a result of both low bicarbonate levels in the metabolic system and high levels of CO2 in the respiratory system.

Further Reading:

Arterial blood gases (ABG) are an important diagnostic tool used to assess a patient’s acid-base status and respiratory function. When obtaining an ABG sample, it is crucial to prioritize safety measures to minimize the risk of infection and harm to the patient. This includes performing hand hygiene before and after the procedure, wearing gloves and protective equipment, disinfecting the puncture site with alcohol, using safety needles when available, and properly disposing of equipment in sharps bins and contaminated waste bins.

To reduce the risk of harm to the patient, it is important to test for collateral circulation using the modified Allen test for radial artery puncture. Additionally, it is essential to inquire about any occlusive vascular conditions or anticoagulation therapy that may affect the procedure. The puncture site should be checked for signs of infection, injury, or previous surgery. After the test, pressure should be applied to the puncture site or the patient should be advised to apply pressure for at least 5 minutes to prevent bleeding.

Interpreting ABG results requires a systematic approach. The core set of results obtained from a blood gas analyser includes the partial pressures of oxygen and carbon dioxide, pH, bicarbonate concentration, and base excess. These values are used to assess the patient’s acid-base status.

The pH value indicates whether the patient is in acidosis, alkalosis, or within the normal range. A pH less than 7.35 indicates acidosis, while a pH greater than 7.45 indicates alkalosis.

The respiratory system is assessed by looking at the partial pressure of carbon dioxide (pCO2). An elevated pCO2 contributes to acidosis, while a low pCO2 contributes to alkalosis.

The metabolic aspect is assessed by looking at the bicarbonate (HCO3-) level and the base excess. A high bicarbonate concentration and base excess indicate alkalosis, while a low bicarbonate concentration and base excess indicate acidosis.

Analyzing the pCO2 and base excess values can help determine the primary disturbance and whether compensation is occurring. For example, a respiratory acidosis (elevated pCO2) may be accompanied by metabolic alkalosis (elevated base excess) as a compensatory response.

The anion gap is another important parameter that can help determine the cause of acidosis. It is calculated by subtracting the sum of chloride and bicarbonate from the sum of sodium and potassium.

Cement contains lime, which is a powerful alkali, and this can cause a serious eye emergency that requires immediate treatment. Alkaline chemicals, such as oven cleaner, ammonia, household bleach, drain cleaner, oven cleaner, and plaster, can also cause damage to the eyes. They lead to colliquative necrosis, which is a type of tissue death that results in liquefaction. On the other hand, acids cause damage through coagulative necrosis. Common acids that can harm the eyes include toilet cleaners, certain household cleaning products, and battery fluid.

The initial management of a patient with cement or alkali exposure to the eyes should be as follows:

1. Irrigate the eye with a large amount of normal saline for 20-30 minutes.
2. Administer local anaesthetic drops every 5 minutes to help keep the eye open and alleviate pain.
3. Monitor the pH every 5 minutes until a neutral pH (7.0-7.5) is achieved. Briefly pause irrigation to test the fluid from the forniceal space using litmus paper.

After the initial management, a thorough examination should be conducted, which includes the following steps:

1. Examine the eye directly and with a slit lamp.
2. Remove any remaining cement debris from the surface of the eye.
3. Evert the eyelids to check for hidden cement debris.
4. Administer fluorescein drops and check for corneal abrasion.
5. Assess visual acuity, which may be reduced.
6. Perform fundoscopy to check for retinal necrosis if the alkali has penetrated the sclera.
7. Measure intraocular pressure through tonometry to detect secondary glaucoma.

Once the eye’s pH has returned to normal, irrigation can be stopped, and the patient should be promptly referred to an ophthalmology specialist for further evaluation.

Potential long-term complications of cement or alkali exposure to the eyes include closed-angle glaucoma, cataract formation, entropion, keratitis sicca, and permanent vision loss.

Infective endocarditis is a condition that can be identified by certain signs, although none of them are definitive proof of the disease. The most reliable indicators are the presence of a heart murmur and a fever. However, there are other signs that are commonly associated with infective endocarditis, including splinter hemorrhages, Osler’s nodes, Janeway lesions, and Roth spots. It is important to note that these signs can also appear in other conditions, and they are not always present in patients with infective endocarditis. In fact, each of these signs is typically found in less than a third of patients diagnosed with the disease.

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.

Chickenpox is a highly contagious illness caused by the varicella-zoster virus, a DNA virus from the Herpesviridae family. Most cases are mild to moderate, and the infection usually resolves on its own. Severe complications are rare but can occur, especially in individuals with weakened immune systems or underlying health conditions.

The incubation period for chickenpox is typically between 14 to 21 days. It is contagious from a few days before the rash appears until about a week after the first lesions show up.

The common clinical features of chickenpox include:

– Fever, which lasts for approximately 3-5 days.
– The initial rash starts as flat red spots and progresses into raised bumps.
– These bumps then turn into fluid-filled blisters and eventually form pustules surrounded by redness.
– The lesions are extremely itchy.
– The rash reaches its peak around 48 hours in individuals with a healthy immune system.
– The rash tends to be more concentrated on the face and trunk, with fewer lesions on the limbs.
– The blisters eventually dry up and form crusts, which can lead to scarring if scratched.
– Headache, fatigue, and abdominal pain may also occur.

Chickenpox tends to be more severe in teenagers and adults compared to children. Antiviral treatment should be considered for these individuals if they seek medical attention within 24 hours of rash onset. The recommended oral dose of aciclovir is 800 mg taken five times a day for seven days.

Immunocompromised patients and those at higher risk, such as individuals with severe cardiovascular or respiratory disease or chronic skin disorders, should receive antiviral treatment for ten days, with at least seven days of intravenous administration.

Although most cases are relatively mild, if serious complications like pneumonia, encephalitis, or dehydration are suspected, it is important to refer the patient for hospital admission.

For more information, you can refer to the NICE Clinical Knowledge Summary on Chickenpox.
https://cks.nice.org.uk/topics/chickenpox/

According to the RCEM, the minimum time for cuff inflation during Bier’s block is 20 minutes, while the maximum time is 45 minutes.

Further Reading:

Bier’s block is a regional intravenous anesthesia technique commonly used for minor surgical procedures of the forearm or for reducing distal radius fractures in the emergency department (ED). It is recommended by NICE as the preferred anesthesia block for adults requiring manipulation of distal forearm fractures in the ED.

Before performing the procedure, a pre-procedure checklist should be completed, including obtaining consent, recording the patient’s weight, ensuring the resuscitative equipment is available, and monitoring the patient’s vital signs throughout the procedure. The air cylinder should be checked if not using an electronic machine, and the cuff should be checked for leaks.

During the procedure, a double cuff tourniquet is placed on the upper arm, and the arm is elevated to exsanguinate the limb. The proximal cuff is inflated to a pressure 100 mmHg above the systolic blood pressure, up to a maximum of 300 mmHg. The time of inflation and pressure should be recorded, and the absence of the radial pulse should be confirmed. 0.5% plain prilocaine is then injected slowly, and the time of injection is recorded. The patient should be warned about the potential cold/hot sensation and mottled appearance of the arm. After injection, the cannula is removed and pressure is applied to the venipuncture site to prevent bleeding. After approximately 10 minutes, the patient should have anesthesia and should not feel pain during manipulation. If anesthesia is successful, the manipulation can be performed, and a plaster can be applied by a second staff member. A check x-ray should be obtained with the arm lowered onto a pillow. The tourniquet should be monitored at all times, and the cuff should be inflated for a minimum of 20 minutes and a maximum of 45 minutes. If rotation of the cuff is required, it should be done after the manipulation and plaster application. After the post-reduction x-ray is satisfactory, the cuff can be deflated while observing the patient and monitors. Limb circulation should be checked prior to discharge, and appropriate follow-up and analgesia should be arranged.

There are several contraindications to performing Bier’s block, including allergy to local anesthetic, hypertension over 200 mm Hg, infection in the limb, lymphedema, methemoglobinemia, morbid obesity, peripheral vascular disease, procedures needed in both arms, Raynaud’s phenomenon, scleroderma, severe hypertension and sickle cell disease.

The guidelines from the European League Against Rheumatism (EULAR) regarding the diagnosis of gout state that if a joint becomes swollen, tender, and red, and if acute pain develops in that joint over a period of 6-12 hours, it is highly likely to be a crystal arthropathy. Pseudogout is also a possibility, but it is much less likely. In this case, gout is the most probable diagnosis.

The joint that is most commonly affected in acute gout is the first metatarsal-phalangeal joint, which accounts for 50-75% of cases.

The main cause of gout is hyperuricaemia, and the clinical diagnosis can be confirmed by the presence of negatively birefringent crystals in the synovial fluid aspirate.

For the treatment of acute gout attacks, NSAIDs or colchicine are generally used.

If IV methylene blue is obtained, it is typically used to treat a specific cause. However, if there is no response to methylene blue, alternative treatments such as hyperbaric oxygen or exchange transfusion may be considered. In cases where the cause is NADH-methaemoglobinaemia reductase deficiency, ascorbic acid can be used as a potential treatment.

Further Reading:

Methaemoglobinaemia is a condition where haemoglobin is oxidised from Fe2+ to Fe3+. This process is normally regulated by NADH methaemoglobin reductase, which transfers electrons from NADH to methaemoglobin, converting it back to haemoglobin. In healthy individuals, methaemoglobin levels are typically less than 1% of total haemoglobin. However, an increase in methaemoglobin can lead to tissue hypoxia as Fe3+ cannot bind oxygen effectively.

Methaemoglobinaemia can be congenital or acquired. Congenital causes include haemoglobin chain variants (HbM, HbH) and NADH methaemoglobin reductase deficiency. Acquired causes can be due to exposure to certain drugs or chemicals, such as sulphonamides, local anaesthetics (especially prilocaine), nitrates, chloroquine, dapsone, primaquine, and phenytoin. Aniline dyes are also known to cause methaemoglobinaemia.

Clinical features of methaemoglobinaemia include slate grey cyanosis (blue to grey skin coloration), chocolate blood or chocolate cyanosis (brown color of blood), dyspnoea, low SpO2 on pulse oximetry (which often does not improve with supplemental oxygen), and normal PaO2 on arterial blood gas (ABG) but low SaO2. Patients may tolerate hypoxia better than expected. Severe cases can present with acidosis, arrhythmias, seizures, and coma.

Diagnosis of methaemoglobinaemia is made by directly measuring the level of methaemoglobin using a co-oximeter, which is present in most modern blood gas analysers. Other investigations, such as a full blood count (FBC), electrocardiogram (ECG), chest X-ray (CXR), and beta-human chorionic gonadotropin (bHCG) levels (in pregnancy), may be done to assess the extent of the condition and rule out other contributing factors.

Active treatment is required if the methaemoglobin level is above 30% or if it is below 30% but the patient is symptomatic or shows evidence of tissue hypoxia. Treatment involves maintaining the airway and delivering high-flow oxygen, removing the causative agents, treating toxidromes and consider giving IV dextrose 5%.

According to the latest guidelines from NICE and the BNF, the recommended initial treatment for typhoid fever is cefotaxime. It is important to note that infections originating from the Middle-East, South Asia, and South-East Asia may have multiple antibiotic resistance, so it is advisable to test for sensitivity. In cases where the microorganism is found to be sensitive, ciprofloxacin can be considered as a suitable alternative.

For the treatment of women with lower urinary tract infections (UTIs) who are not pregnant, it is recommended to consider either a back-up antibiotic prescription or an immediate antibiotic prescription. This decision should take into account the severity of symptoms and the risk of developing complications, which is higher in individuals with known or suspected abnormalities of the genitourinary tract or weakened immune systems. The evidence for back-up antibiotic prescriptions is limited to non-pregnant women with lower UTIs where immediate antibiotic treatment is not deemed necessary. It is also important to consider previous urine culture and susceptibility results, as well as any history of antibiotic use that may have led to the development of resistant bacteria. Ultimately, the preferences of the woman regarding antibiotic use should be taken into account.

If a urine sample has been sent for culture and susceptibility testing and an antibiotic prescription has been given, it is crucial to review the choice of antibiotic once the microbiological results are available. If the bacteria are found to be resistant and symptoms are not improving, it is recommended to switch to a narrow-spectrum antibiotic whenever possible.

The following antibiotics are recommended for non-pregnant women aged 16 years and older:

First-choice:
– Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days (if eGFR >45 ml/minute)
– Trimethoprim 200 mg taken orally twice daily for 3 days (if low risk of resistance*)

Second-choice (if there is no improvement in lower UTI symptoms on first-choice treatment for at least 48 hours, or if first-choice treatment is not suitable):
– Nitrofurantoin 100 mg modified-release taken orally twice daily for 3 days (if eGFR >45 ml/minute)
– Pivmecillinam 400 mg initial dose taken orally, followed by 200 mg taken orally three times daily for 3 days
– Fosfomycin 3 g single sachet dose

*The risk of resistance may be lower if the antibiotic has not been used in the past 3 months, previous urine culture suggests susceptibility (although this was not used), and in younger individuals in areas where local epidemiology data indicate low resistance rates. Conversely, the risk of resistance may be higher with recent antibiotic use and in older individuals in residential facilities.

Hyperosmolar hyperglycaemic state (HHS) is a syndrome that occurs in people with type 2 diabetes and is characterized by extremely high blood glucose levels, dehydration, and hyperosmolarity without significant ketosis. It can develop over days or weeks and has a mortality rate of 5-20%, which is higher than that of diabetic ketoacidosis (DKA). HHS is often precipitated by factors such as infection, inadequate diabetic treatment, physiological stress, or certain medications.

Clinical features of HHS include polyuria, polydipsia, nausea, signs of dehydration (hypotension, tachycardia, poor skin turgor), lethargy, confusion, and weakness. Initial investigations for HHS include measuring capillary blood glucose, venous blood gas, urinalysis, and an ECG to assess for any potential complications such as myocardial infarction. Osmolality should also be calculated to monitor the severity of the condition.

The management of HHS aims to correct dehydration, hyperglycaemia, hyperosmolarity, and electrolyte disturbances, as well as identify and treat any underlying causes. Intravenous 0.9% sodium chloride solution is the principal fluid used to restore circulating volume and reverse dehydration. If the osmolality does not decline despite adequate fluid balance, a switch to 0.45% sodium chloride solution may be considered. Care must be taken in correcting plasma sodium and osmolality to avoid complications such as cerebral edema and osmotic demyelination syndrome.

The rate of fall of plasma sodium should not exceed 10 mmol/L in 24 hours, and the fall in blood glucose should be no more than 5 mmol/L per hour. Low-dose intravenous insulin may be initiated if the blood glucose is not falling with fluids alone or if there is significant ketonaemia. Potassium replacement should be guided by the potassium level, and the patient should be encouraged to drink as soon as it is safe to do so.

Complications of treatment, such as fluid overload, cerebral edema, or central pontine myelinolysis, should be assessed for, and underlying precipitating factors should be identified and treated. Prophylactic anticoagulation is required in most patients, and all patients should be assumed to be at high risk of foot ulceration, necessitating appropriate foot protection and daily foot checks.

Ciprofloxacin is known to inhibit the activity of cytochrome P450 enzymes, which can lead to increased levels of theophylline in the blood. Therefore, it is recommended to avoid prescribing ciprofloxacin and theophylline together. For more information on the interactions between these two medications, you can refer to the relevant section on theophylline interactions in the British National Formulary (BNF).