Guillain Barre in ED - acute inflammatory demyelinating polyneuropathy - ascending motor paresis with lower motor neurone features with some dyautonomia and cranial nerve abn - don’t forget to check FVC and FIP.
GBS presents occasionally to ED as paediatric or adult weakness. Key components of the clinical picture include
-varying degrees of lower limb weakness ( sometimes presenting as new onset ‘cannot walk’), LMN signs in ascending pattern
-usually mostly motor, but some sensory deficit
-decreased or equivocal reflexes
- dysautonomia (fluctuations in hr bp diaphoresis )
- respiratory failure with chest wall muscle weakness
Remember to check FVC (<15L/kg) and FIP (<-25 cmh2o) as indicators for intubation and mechanical ventilation.
Avoid suxamethonium and optimize vitals with short acting vasoactive agents ( esmolol if hypertensive, noradrenaline if hypotensive) prior to RSI.
Abnormal Uterine Bleeding - causes classified by PALM COEIN - Polyp - Adenomyosis- Leiomyoma - Malignancy - Coagulation - Ovulatory - Endometrial - Iatrogenic - not classified
ACOG 2011 updated their approach to classification of abnormal uterine bleeding in non pregnant patients. PALM - structural vs COEIN - nonstructural.
Myasthenic patients may present to ED with shortness of breath without obvious signs of distress ( because resp accessory muscles are weak and fatiguing !)
Common precipitants are infections and antibiotics or other meds - sometimes disease course
Measure the negative inspiratory pressure or the FVC - if <25 cm h2o or 15L/kg - discuss with icu and neurology need for:
NIV or CVM
Plasmapharesis or Steroids
Physostigmine is NOT used for acute myasthenia
Management in ED - know the key consultant issues, goals of management and remember DRS ABCDE. When considering RSI - think : HHAARRMMS and the P’s. When ventilating - use a ppv, lung protective or obstructive strategy.
Evidence deficit for burns formulas and fluid type - ANZBA recommends parklands formula in adults using Hartmanns
4ml/kg/tbsa has been the standard formula used in most ed settings in Australia and ANZBA has further endorsed this for adults.
Most Paediatric centres in Australia actually suggest 2 or 3 ml/kg / tbsa - which is a modified formula
Hartmanns is the suggested fluid
Remember to provide maintenance in children split between
NGT 10 ml/ hr as feeds or ors
Iv Hartmanns 5% dextrose.
Remember to suntract any bolus NS from parklands.
If shock - NS 10-20ml/kg
Modified parklands - 2 or 3 ml/kg/tbsa Hartmanns
( sorts our deficit)
10ml/hr NGT ors or milk
Iv Hartmanns 5% dextrose.
Assess for losses
Check out :
Use a Lund and browder chart in children and Wallace’s rule of nines in adults.
The best clinical indicator of inhalational burn is stridor - if absent - facial or lip signs are inaccurate at predicting supraglottic or glottic injury. Use awake oral anaesthetic laryngoscopy with ketamine dissociation to exclude inhalational injury with fibreoptic or video laryngoscopy.